The cognitive load of inpatient consults involving immune-related adverse events.
Authors: Sam Brondfield, Jordyn Silverstein, Kimberly de Dios, Zoe Quandt
Journal: Journal of Clinical Oncology (2023)

11033 Background: Immune-related adverse events (irAE) requiring hospitalization involve complex, multidisciplinary management. Expertise in oncology and/or the affected organ(s) may be required in the form of inpatient consults. Trainees (fellows and residents) often provide such consults. irAE consults may be rich learning opportunities, but it is unclear whether the cognitive load, or mental effort, required for these complex cases may overwhelm trainees and impair learning. To investigate the cognitive load of irAE consults, we surveyed trainees who had recently completed an irAE consult and compared the results to a control dataset. Methods: Between October 2021 and January 2023, we identified patients hospitalized due to irAEs at the University of California, San Francisco by reviewing patient lists (oncology consults and hospital medicine admissions) daily. We emailed the published Consult Cognitive Load (CCL) survey to any residents or fellows who had signed initial consult notes in the charts of identified patients. The CCL uses 4-point scales to measure three types of cognitive load related to one consult: intrinsic load (IL) related to the consult task itself, extraneous load (EL) related to distractions during the consult, and germane load (GL), the mental effort left over for learning after IL and EL are accounted for. IL, EL, and GL scores range from 4 to 16. Using two-tailed t tests, we compared mean IL, EL, GL, and total cognitive load (the sum of IL, EL, and GL) between the irAE group and a control group of fellows and residents who performed a variety of consults at five University of California hospitals during a 2018-2019 study (n = 142). Detecting a difference of 0.5 with a variance of 0.5 (calculated for the control group), 80% power, and 95% confidence required an irAE group sample size of 18. Results: Of 36 trainees contacted for the irAE group, 18 completed the CCL (50% response rate, 61% fellows, 39% residents). The irAE group and the control group (80% fellows, 17% residents, 3% not reported) spanned multiple specialties. Total cognitive load (p = 0.49) and IL (p = 0.95) did not differ. EL was significantly lower (8.4 vs 10.3, p = 0.002) and GL higher (11.9 vs 10.8, p = 0.04) in the irAE group. Conclusions: Trainees experienced similar cognitive load when performing irAE consults as compared to other consults, but the sources of cognitive load differed. Trainees performing irAE consults expended less mental effort on distractions (EL) and more on learning (GL) as compared to other consults. The consult task itself (IL) imposed a similar amount of cognitive load whether or not it was an irAE consult. Complex irAE cases did not overwhelm trainees or preclude learning; rather, trainees performing irAE consults exhibited a sharpened focus on the task at hand and extracted more learning than trainees performing other consults. Educators should foster trainee exposure to inpatient irAE consults to promote worthwhile learning.